Provider Demographics
NPI:1780855981
Name:JEFFERSON, DANITA RENEE (LMT)
Entity Type:Individual
Prefix:
First Name:DANITA
Middle Name:RENEE
Last Name:JEFFERSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2330 SCENIC HWY S STE 115
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-3115
Mailing Address - Country:US
Mailing Address - Phone:678-824-7005
Mailing Address - Fax:
Practice Address - Street 1:2330 SCENIC HWY S STE 115
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-3115
Practice Address - Country:US
Practice Address - Phone:678-824-7005
Practice Address - Fax:678-252-2104
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-14
Last Update Date:2021-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT011369225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist